Cerebrospinal Fluid ExaminationNeurology DepartmentUNPAD Faculty of MedicineBandung 2006dr. Ahmad Rizal, SpS

Aim of the examination

Diagnostic Treatment evaluation or follow upPrognostic

Cerebrospinal Fluid (CSF)AKA Liquor Cerebrospinalis (LCS)

Location Ventricular systemSubarachnoid space (including cysternal system)

Function Protect CNS from mechanical insult (as a cushion)Maintain the equilibrium of neuronal and glial cellsRemove waste products of neuronal metabolism

Anatomy anatomi otak dipotong dari sampingPembentukan tempat utama, anatomi plex. chorSirkulasi anatomi lagi, lengkap dengan lubang2nyaPembuangan anatomi sinus sagitalisFungsiKomposisiNormal valuesCSF

AnatomyCSF

FormationRate 0.35 mL/minute ~ 500 mL/dayFormed by :Choroid plexuses at :Floor of each lateral ventricles (largest and most important)Roofs of the third and fourth ventricles (smaller)Capillary beds that supply the pia and arachnoid (smaller)Ependyma and subjacent glial elements (smaller)CSF

Anatomy (site of CSF formation)CSF

Formation (cont.)A complex process :Active transport (expenditure of energy)Passive diffusion

Active transportCuboid epithelial cells (in choroid plexus) secrete Na ion Positive potential attracts negative ion especially Cl Many of ionic solutes increase osmotic pressureWater and other solutes follow in maintaining osmotic equilibrium

Passive diffusionContinual diffusion occurs at Ependym and vascular bedsCSF

Circulation

Lateral ventriclesMonro foramenThird ventricleSylvii aqueductFourth ventricleLuschka and Magendie foraminaSubarachnoid space (cysternal system)Superior and lateral convexity of brain hemispheresArachnoid villiVenous sinusesVenous blood flow to the heartCSF

gambar yang ada sirkulasi dan lubang2 yang diberi nama masing2 (di buku apa ya???)CSF

Absorption Mainly at Arachnoid villi (Arachnoid granulation or Pacchionian bodies)Others (smaller) : veins and capillary of piamatterUnidirectional (valve)

Mechanism Depends on :Hydrostatic pressure (high to low) Colloid osmotic pressure (low to high)Active transport by cells forming the walls of the arachnoid villi

CSF

Site of Absorption

DynamicsTotal volume of CSF : 75 100 mL ( 15-40 mL at ventricular system)Rate of production 0.35 mL/min ~ 500 mL/dayDaily turn over 4-5 timesCSF

CompositionWater (main component)Small amount of proteinIons: Na, K, Ca, Mg, Cl GlucoseA few white cell ( < 5/mm3 is normal )Organic constituentsDispersed gases (O2 and CO2)CSF

Normal valuesColorClear, colorlessOpening Pressure70-200 mmH2OCell 0-5/mm3 (lymphocyte or MN cell)Glucose45-80 mg%Protein5-15 mg%(intraventricular)10-25 mg%(cysternal)15-45 mg%(lumbar)-globulin5-22 % of total proteinOsmolarity295 mOsmol/LpH7.31Sodium (Natrium)142-150 mEq/LPotassium (Kalium)2.2-3.3 mEq/LChloride120-130 mEq/LMagnesium2.7 mEq/LCO2 25

CSF

CSFColorClear, colorlessChange in color : Cell > 200 / mm3 (RBC > 1000 red color)Traumatic puncture : 3-tubes test

Get palerclearbloodxanthochromicbloodremain unchanged

CSFOpening PressureDepends on : Rate of formation and absorptionPatency of ventricular and subarachnoid system

Measurement : Manometer during lumbar or cysternal puncture

Position :Lateral decubitus : Normal pressure 70-200 mmH2OSitting: 280 mmH2O Slightly increased in several condition: Coughing or strainingPressure on abdomen

CSF

Opening Pressure (cont.)

Fluctuative changes in heart beat and respiratory cycle

Change in flow disturbance Queckenstedt Test pressure on both jugular veins results in increase CSF pressure that returns to normal within 10 sec.

CSF obstruction no or slight increase of CSF pressure

Cell Leucocytes or PMN means pathologic i.e. infection of bacterial, fungal, viral, chemical agents, tumor

Proteinhigher than normal limit means pathologic condition

Glucosetwo third of blood glucose; below 40 mg% abnormal (i.e in pyogenic infection, tuberculous/fungal meningitis)

Electrolyteslow chloride concentration meningitis (but not specific)

Disorders of CSF

~ Flow disturbanceSeveral causes of flow disturbance:TumorInfectionSubarachnoid bleedingAqueductal stenosis

CSF

Flow disturbance: Obstruction of ventricular system or subarachnoid space results in hydrocephalus

2 kinds of hydrocephalus:CommunicatingNon communicatingCSF

Disorders of CSF (cont.)Communicating hydrocephalusCommon in adultFree communication between ventricles and subarachnoid spaceObstruction at subarachnoid spaceCaused by inflammation, subarachnoid bleeding, tumor growth

Disorders of CSF (cont.)Non-communicating hydrocephalus :Common in childrenCaused by aqueduct stenosis, overgrowth of Luschka and Magendie foramina

Lumbar PunctureIndication :

Measure CSF pressureObtain sample for cell count, chemical work-up, bacteriologyIntrathecal treatment/procedure : spinal anesthesiachemotherapies for cancerantibioticsOther diagnostic procedure : myelography, pneumoencephalography, scintigraphic cysternographyCSF

Lumbar PunctureContraindications:

Infection at the site of LP (low back region) Use of anticoagulants Increased intra-cranial pressure Severe hemorrhagic diathesis CNS mass lesion in posterior fossa Suspect venous sinus occlusion

CSF

Some conditions that require LPWhen we suspect meningitis or encephalitis To diagnose meningeal carcinomatosis To diagnose tertiary syphilis To diagnose meningeal leukemia To diagnose staging of lymphomas Follow up therapy for meningitis CSF

Some conditions that require LPEvaluation of dementia Evaluation for Guillain-Barre Treatment of pseudotumor cerebri Evaluation for multiple sclerosis Rule out subarachnoid hemorrhage (after neg. head CT) Instillation of drugs, anesthetics, or radiographic media into CNS

CSF

CSF|LPTechniquePreparation : Explain the procedure to patientObtain informed consentExclude possibility of increased ICP or CNS mass lesion (eye exam/ head CT)Take blood sample for glucose 15 before LPPositioning of the patient determine its success!!Lateral decubitus in full flexion postureAt the bed sideSmall cushion on head or knee (if needed)

CSF|LPTechniqueSite of punctureInter-vertebral space at vertebra L3 L4Imaginary line connecting iliac crests Other site (if failed) : L2-L3 or L4-L5Infant/children at L4-L5

CSF|LPTechniqueSitting position if failed in recumbent (2-3 times)Measure (opening) pressure

Patient preparationAseptic technique : Clean the area using iodine 10% application in round movementstarting from the center Change glove onceUse sterile covering/towel

CSF|LPTechniqueInsertion :All tools available : spinal needle (18,19,20), manometer, sterile bottles (3)Local anesthetic (lidocaine 1-2%) :0.1-0.2 mL subcutaneous and 0.2-0.5 mL deeperIntroduce spinal needle, with bevel facing up,into interspace, in a horizontal direction, with slightly cephalad inclination ("aim for the belly button"). Always have stylet in place when maneuvering needle in the interspace

CSF|LP

Measure opening pressure (normal is 100-250 mmHg): If pressure elevated, ask pt to relax and ensure that there is no abdominal compression or breath holding (straining and abdominal pressure can increase ICP).

If pressure markedly elevated, remove only 5 cc of spinal fluid and remove needle immediately.

Else, collect 15-20 cc in four collection tubes (2 cc per tube), and remove needle (with stylet in place). Can send extra fluid in tube #3, or in extra red-top (#5).

Instruct pt to lie flat for approx. 4 hrs to minimize post LP headache (caused by CSF leakage).

CSF|LPComplication

HeadacheBackacheIntracranial subdural hematomaInfectionCSF leakHerniation

Tengkyu